Stage 4 NSCLC-Adenocarcinoma maintenance choices - 1294624

Hi kspell143,

Welcome to Grace. I'm sorry for the wait. Unfortunately the answers aren't clear when it comes to maintenance with or without avaistin.

"Many large clinical trials have been conducted in attempts to identify the best treatment strategy for patients with NSCLC. The addition of agents targeting VEGF, use of histology to guide chemotherapy decisions, and the addition of maintenance therapy have all shown incremental improvements in OS, particularly for nonsquamous histology. Targeting of EGFR in wild-type NSCLC has also resulted in some success in improving OS. Pemetrexed and bevacizumab have transformed treatment options for patients with nonsquamous NSCLC and, along with erlotinib, have recast the treatment paradigm to include well-tolerated maintenance therapies that extend survival for patients with NSCLC. No data support combination maintenance therapy as superior to single agent, but whether an optimal single agent exists is not clear. The authors favor choosing a platinum partner, typically pemetrexed or paclitaxel, based on the desired toxicity profile and adding bevacizumab unless contraindicated. The induction phase should be followed by maintenance bevacizumab for paclitaxel-based chemotherapy and maintenance pemetrexed or combination pemetrexed and bevacizumab maintenance for pemetrexed-based chemotherapy, providing the patient has stable or responsive disease and manageable toxicity after four cycles of platinum chemotherapy. The ECOG 5508 trial may help determine whether an incremental benefit with bevacizumab is possible when added to maintenance pemetrexed therapy." http://theoncologist.alphamedpress.org/content/20/3/299.full

The question that should be asked is why isn't a checkpoint inhibitor being considered. It's possible there are autoimmune problems that could cause problems.

cont'd.

An FYI about reading a long article that includes research data/methods, etc. I often skip a lot of the middle part at least at first and read conclusions and discussions. That's where clinical research discuss implications for patient use.

Often a break is taken after induction therapy (carbo/taxol/avas) where the person is watched closely by ct scans and physical check up by onc every 6 weeks or so. So when progression starts it will be caught early enough to treat and you have a chance to recovery from platinum based chemo which will be the most toxic of chemo. This is a good option for people who want or need a break to recover or go on vacation or sit on the couch without feeling sick. On the other hand if your oncologist and/or you aren't comfortable with a break continuing treatment may not be up for discussion. That's fine too.

The most recent research shows that anyone with any pdl-1 expression over 1% can benefit from checkpoint inhibitor immunotherapies such as pembrolizamub. Pembro has shown longer lasting efficacy than cytotoxic agents aka chemo.

If your health system requires you to use chemo until progression before allowing the use of immunotherapy, alimta alone is much much more common than avaistin alone and many people use alimta with avaitin but the until data from the ecog 5508 trial are mature we just don't know which is best.

Keep us posted and best of luck,
Janine

Thanks to Janine for posting that excellent information. It certainly makes sense to investigate immunotherapies.

The E5508 clinical trial Janine mentioned is directly testing maintenance therapy with Bevacizumab, Pemetrexed, or a combination of Bevacizumab and Pemetrexed following Carboplatin, Paclitaxel and Bevacizumab for advanced non-squamous NSCLC.

It sounds like you're in good hands. Sloan Kettering is an outstanding cancer center. Keep us posted.

All the best hopes,
Janine